Diagnostic accuracies of endoscopic ultrasound-guided fine-needle aspiration with distinct negative pressure suction techniques in solid lesions: A retrospective study

  • Authors:
    • Ronghua Wang
    • Jinlin Wang
    • Yawen Li
    • Yaqi Duan
    • Xiaoli Wu
    • Bin Cheng
  • View Affiliations

  • Published online on: March 28, 2017     https://doi.org/10.3892/ol.2017.5942
  • Pages: 3709-3716
Metrics: Total Views: 0 (Spandidos Publications: | PMC Statistics: )
Total PDF Downloads: 0 (Spandidos Publications: | PMC Statistics: )


Abstract

Endoscopic ultrasound (EUS)-guided fine-needle aspiration (EUS-FNA) is highly accurate in obtaining specific diagnoses for various diseases. The present study aimed to evaluate the diagnostic yields, accuracies and sampling adequacies, of slow-pull, 5 ml suction and 10 ml suction techniques in EUS‑FNA of solid lesions. The present study was a retrospective comparative study, which was performed in tertiary academic centers, recognized for their expertise in EUS and EUS‑guided FNA. The present study involved 149 patients who underwent EUS‑FNA of solid masses. A total of 34 (22.8%), 37 (24.8%) and 78 (52.4%) patients underwent EUS‑FNA with slow‑pull, 5 ml suction and 10 ml suction techniques, respectively. The EUS‑FNA cytology and histology results were compared with those from the gold standard of surgical histopathology [hematoxylin‑eosin staining; immunohistochemical test of cluster of differentiation (CD) 79a, CD20 and flow cytometry test] or long‑term clinical follow‑up. The present retrospective comparative study demonstrated that the diagnostic yields and accuracies of EUS‑FNA with slow‑pull (86.1%) were significantly superior to those achieved with 5 ml suction (83.3%) or 10 ml suction (69.9%; P<0.0001; χ2 test). Consistently, 86.5% (32/37) of the samples obtained from the 5 ml suction group were adequate for histological diagnosis. By contrast, 70.6 (24/34) and 85.9% (67/78) of samples from the slow‑pull and 10 ml suction groups were adequate for histological diagnosis, respectively. The samples obtained using 10 ml suction contained more blood compared with those obtained via slow‑pull and 5 ml suction (P=0.0056; χ2 test). No complications were noted in any of the three groups. The samples that were obtained for histopathological diagnosis using 5 ml suction were superior to those obtained using slow‑pull or 10 ml suction. Additional multi‑central prospective studies in which EUS‑FNA is performed with variable negative pressures are required to improve the defining of the diagnostic roles of those techniques.

Introduction

Endoscopic ultrasound (EUS)-guided fine-needle aspiration (EUS-FNA) has been reported to be a sensitive method for tissue sampling of suspicious lesions of the gastrointestinal lumen and adjacent structures, including pancreaticobiliary and esophageal lesions, gastric malignancies and mediastinal and intra-abdominal lymphadenopathies (16). The diagnostic accuracy of EUS-FNA ranges between 60 and 90%, according to the site being evaluated (1,711). Cytological study of the material obtained by FNA allows for the evaluation of cellular findings that are indicative of malignancy. However, EUS-FNA has a number of limitations. Certain neoplasms, including lymphomas, stromal tumors and well-differentiated neoplasias are difficult to diagnose without histological samples, since tissue architecture and cell morphology are essential for accurate pathological assessments, which include immunohistochemical analyses in such cases (1214). In addition, the accuracy of EUS-FNA depends on the presence of an on-site cytopathologist or cytotechnician to assess the specimen adequacy (15), and to determine whether additional samples are required to perform ancillary studies (16,17).

In an attempt to overcome these diagnostic limitations and optimize the accuracy, efficiency and quality of EUS-FNA specimens, various investigators have attempted to obtain tissue fragments with high negative pressure or with needles of varying diameters (1821). The use of suction during FNA varies widely. No standard suction technique has been established. A randomized trial involving 52 patients compared suction and no suction during EUS-FNA of the pancreas (22). No significant differences in diagnostic yield were observed. In a previous study, Kudo et al (23) utilized high negative pressure mechanical suction (35 ml of a 60 ml syringe) using a 22-gauge (G) needle, and this process yielded tissue cores that were adequate for histological evaluation in 96% of the solid masses, however, the approach was not advantageous compared with cytology alone. In addition, it may be assumed that suctioning dilutes the specimen with blood, and the stylet injures malignant cells. These assumptions raise the possibility of atypical results.

Therefore, a retrospective study was performed to investigate the feasibilities and yields of EUS-FNA combined with 10 ml suction (negative pressure applied with 10 ml syringes), 5 ml suction (negative pressure applied with a 5 ml syringe) and slow-pull (no stylet) techniques, and to compare characteristics of the samples obtained with each of the three techniques in terms of contamination with blood.

Materials and methods

Study design and patients

The present study was a retrospective, case-control study. A total of 149 patients who were referred for EUS-guided FNA tissue acquisition for the evaluation of intra-intestinal or extra-intestinal mass lesions and/or peri-intestinal lymph nodes between February 2013 and July 2014 were retrospectively identified from a prospectively collected endoscopy database at Tongji Hospital Endoscope Center (Wuhan, China). Patient characteristics are presented in Table I. Patients were classified into EUS/slow-pull, EUS/5 ml suction or EUS/10 ml suction groups (the patients who underwent EUS-FNA with the 22-G needle system with no stylet, with 5 ml negative pressure and with 10 ml negative pressure). Only patients with surgical pathology or with ≥6 months of clinical follow-up subsequent to EUS were included in the present study. The present authors reviewed the computerized patient record system to obtain patient demographics, lesion sites, EUS characteristics of the lesion and clinical follow-up information.

Table I.

Patient demographic and mediastinal and intra-abdominal lesion characteristics.

Table I.

Patient demographic and mediastinal and intra-abdominal lesion characteristics.

CharacteristicTotal0 ml5 ml10 mlP-value
n 343778
  Age, median545656530.89a
  Gender, n (%) 0.21b
  Male9526 (76.5)22 (59.5)47 (60.3)
  Female54  8 (23.5)15 (40.5)31 (39.7)
Lesion location, n (%) 0.67c
  Pancreatic mass69 (46.3)15 (10.1)19 (12.8)36 (24.2)
  Mediastinal nodes33 (22.1)9 (6.0)7 (4.7)17 (11.4)
  Retroperitoneal lesion32 (21.5)8 (5.4)9 (6.0)14 (9.4)
Othersd15 (10.1)2 (1.3)2 (1.3)11 (7.4)
Needle passes (SD)3.4 (0.7)3.5 (0.7)3.4 (0.8)3.4 (0.6)0.50a
Final diagnosis, n (%) 0.078b
  Malignancy102 (68.5)26 (17.4)29 (19.5)47 (31.5)
  Benign processes47 (31.5)8 (5.4)8 (5.4)31 (20.8)

a Mann-Whitney U-test

b χ2 test

c Fisher's exact test

d Thickened esophagogastric wall, 8 patients; abdominal mass, 4 patients; liver mass, 2 patients; and left adrenal mass, 1 patient; SD, standard deviation.

The EUS-FNA cytology and histology results were compared with those of the gold standard technique of surgical histopathology or long-term clinical follow-up. Intra-procedural and immediate post-procedural complications were monitored and recorded for all patients as part of a standard hospital protocol. The study protocol conformed to the guidelines of the 1975 Declaration of Helsinki (6th revision, 2008) and was approved by the Ethical Committee of Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (Wuhan, China). Written informed consent was obtained from all patients prior to undergoing EUS-FNA. Patients described in the present study provided written informed consent to publish their case details.

Procedural technique

The patients underwent EUS-FNAs with 22-G needles (EchoTip Ultra needle; Wilson-Cook, Winston-Salem, NC, USA) (24). These EUS-FNAs were performed by an experienced endosonographer (>150 EUS procedures/year; >10 years of experience). All procedures were performed with a standard technique, which utilized a linear array echoendoscope (Olympus GF-UCT 240; Olympus Corporation, Tokyo, Japan) and an Alpha 5 Aloka processor (Hitachi-Aloka Medical, Ltd., Tokyo, Japan). During the individual EUS-FNA passes, the stylet was reproducibly removed with a slow-pull technique, and a 10 ml syringe with 5 or 10 ml suction technique (2527) was attached to the proximal end of the needle. The needle was then moved back and forth 12–16 times while applying suction. EUS-FNA was performed using fanning techniques. The lock of the syringe was finally closed prior to the withdrawal of the needle from the lesion. Needle aspirate was placed on glass slides. Ethanol-fixed smears (95% ethanol) were prepared, stained with Papanicolaou stain for 6 h at room temperature and evaluated the next working day by a cytopathologist to perform the preliminary diagnosis. Any visible core specimens and residual aspirate were collected into a liquid preservative (formalin) for subsequent preparation of histological analysis. Immunocytochemistry was performed within 24 h. No cytopathologist was present in the endoscopy room for the on-site sample evaluation.

Pathological assessments of the samples obtained

The pathologist evaluated the quantity and quality of each specimen and determined a histological diagnosis while blinded to the clinical information, cytology and final diagnoses. The quantities of the samples were assessed with the scoring system described by Gerke et al (28). Malignancies and borderline lesions were defined as positive for malignancy. Atypical cells and benign cells were defined as negative for malignancy.

An accurate diagnosis was defined as follows: Positive for malignancy with a final diagnosis of a malignant disease, including carcinoma, neuroendocrine tumor or solid pseudopapillary neoplasm (true positive); and negative for malignancy with the condition ultimately being diagnosed as a nonmalignant disease, including pancreatitis and non-neoplastic pancreatic tissue (true negative). Diagnostic accuracy was defined as the sum of the true positive and true negative values divided by the total number of samples. The adequacy rate was calculated with the following formula: Number of adequate samples/total number of samples.

Clinical diagnostic methodology used for the ultimate diagnosis

Malignant disease was ultimately identified in the patients according to the following criteria: Diagnosis at autopsy following pancreatic cancer-associated mortality; diagnosis based on histopathological analysis of surgically resected specimens; radiological or clinical data indicating evidence of disease progression; and diagnosis based on histopathological analysis of nodules in other organs that demonstrated metastatic progression. In the present study, benign disease was defined by a decrease or lack of change in mass and no change in the obtained clinical data for at least 6.5 months (23).

Outcome measurements

The primary objectives of the present study were to determine the adequacy of tissue acquisition via the EUS-FNA/high negative pressure (HNP) combined technique and to determine the accuracies of the histological diagnoses that were achievable using EUS-FNA combined with slow-pull, 5 ml suction and 10 ml suction. The secondary objectives of the present study were to assess the qualities and quantities of the obtained tissues and the potential for adverse events resulting from the application of this procedure.

Statistical analysis

Statistical analyses were performed with the SPSS (version 18.0; SPSS, Inc., Chicago, IL, USA) and MedCalc software packages (version 12.7.7; MedCalc Software bvba, Ostend, Belgium). The baseline characteristics of the patient population, mass lesions and technical details were calculated. Continuous variables were presented as medians and ranges of values. Categorical variables were reported as proportions with 95% confidence intervals where appropriate. Categorized variables were compared using the Fisher's exact or χ2 two-tailed tests, as appropriate. Quantitative variables were analyzed by the two-sample Student's t-test/one-way analysis of variance (for normal distributions) or the Mann-Whitney U-test (for skewed distributions). P<0.05 was considered to indicate a statistically significant difference. Normally distributed data (n=149) are presented as the mean ± standard deviation.

Results

Patients and lesions characteristics

During the study period, 95 males and 54 females (149 patients) were enrolled. The median age of the patients was 54 years. All lesions were visible via EUS. There were 69 lesions in the pancreas, 33 in the mediastinum, 32 in the retroperitoneal area, 8 in the thickened esophagogastric wall, 4 in the abdominal cavity, 2 in the liver and 1 in the left adrenal gland (Table I). No significant differences were observed between the slow-pull, 5 ml suction and 10 ml suction techniques in terms of patient demographics or lesion locations. Surgical histopathological findings were available for corroboration in 49 (33%) of the cases, flow cytometry data collected following EUS-FNA were available for 6 (4%) patients, and the remaining cases (63%) were corroborated based on long-term clinical follow-up data. The mean clinical follow-up period following EUS was 6.5 months. The final histological diagnoses and diagnostic yields are shown in Tables II and III, respectively. All EUS-FNA procedures were performed with on-site cytopathology evaluations.

Table II.

Final diagnosis, independent of tissue biopsies (EUS-FNA).

Table II.

Final diagnosis, independent of tissue biopsies (EUS-FNA).

DiseasesFinal diagnosis, nAdequate histology sample, %Correct diagnosis, %
Malignant82   80.39   67.7
  Secondary metastatic tumors33   81.8   69.7
  Pancreatic carcinoma22   72.7   81.8
  Lymphoma  9100   77.8
  Gallbladder and biliary cancer  7   57.1   57.1
  Lung carcinoma  5  80  80
  Gastroesophageal carcinoma  5  80  60
  Adrenal carcinoma  1     0100
Borderline lesions21   90.5   90.5
  Neuroendocrine tumor12   77.8   77.8
  Gastrointestinal stromal tumor  9100100
Benign46   82.97   80.85
  Pancreatitis12   91.7   83.3
  Tuberculosis11   72.8   90.9
  No evidence of malignancy16   88.9   66.7
  Solid pseudopapillary neoplasm  2100100
Othersa  4  60  60

a Composed of 3 atypical hyperplasia, 1 reactive lymph node and 1 Castleman disease. EUS-FNA, endoscopic ultrasound-guided fine-needle aspiration.

Table III.

Diagnostic yield and accuracy of normal, moderate and high negative pressure suction techniques in endoscopic ultrasound-guided fine-needle aspiration.

Table III.

Diagnostic yield and accuracy of normal, moderate and high negative pressure suction techniques in endoscopic ultrasound-guided fine-needle aspiration.

Type of negative pressure

Lesion location0 ml, % (n=34)5 ml, % (n=37)10 ml, % (n=78)P-value (χ2 test)
Pancreatic lesion (n=69) 0.0005a
  Sensitivity90   86.764
  Specificity75100   88.2
  PPV90100   81.8
  NPV756075
  Accuracy   85.7   88.9   77.4
Non-pancreatic lesionb (n=80) 0.0086a
  Sensitivity   85.7   84.6   64.7
  Specificity5080   92.9
  PPV   92.3   91.7   94.4
  NPV   33.3   66.7   54.3
  Accuracy   81.2   83.3   71.9
Total (n=149) <0.0001a
  Sensitivity   87.5   85.7   61.9
  Specificity   66.7   87.5   90.3
  PPV   91.396   89.7
  NPV   57.1   63.6   63.6
  Accuracy   83.3   86.1   69.9

a P<0.05

b Non-Pancreatic lesion group consisted of 33 patients with mediastinal nodes, 32 patients with retroperitoneal lesion, 8 patients with thickened esophagogastric wall, 4 cases with abdominal mass, 2 cases with liver mass and 1 case with left adrenal mass. PPV, positive predictive value; NPV, negative predictive value.

Accuracy

The final clinical diagnoses, the percentages of adequate histology samples and the numbers of correct diagnoses are listed in Table II. Of the 149 patients, the final diagnoses were: Malignancy in 82 patients; borderline lesions in 21 patients; and benign lesions in 46 patients. Of the patients with malignancies, 33 patients ultimately received a diagnosis of metastatic tumor, 22 exhibited pancreatic carcinomas, 9 exhibited lymphomas, 7 exhibited gallbladder and biliary cancer, 5 exhibited lung carcinomas, 5 exhibited gastroesophageal carcinomas and 1 exhibited an adrenal carcinoma. Of the patients with borderline lesions, 12 received a diagnosis of neuroendocrine tumors and 9 exhibited gastrointestinal stromal tumors. Among the benign patients, 12 patients received a diagnosis of pancreatitis, 11 exhibited tuberculosis, 16 exhibited benign lesions with histological types that could not be classified (without evidence of malignancy), 2 exhibited solid pseudo-papillaryneoplasma, and the remaining 4 cases exhibited 3 atypical hyperplasias and 1 reactive lymph node, and 1 patient exhibited Castleman disease. Representative cases of lymphoma (Fig. 1), tuberculosis (Fig. 2), pancreatic carcinoma and pancreatitis (Fig. 3) are presented in Figs. 13, respectively. Independent of the tissue biopsies, the final diagnoses were categorized as malignant or benign lesions.

Based on the locations, lesions were classified into 69 pancreatic lesions and 80 non-pancreatic lesions (Table III). The non-pancreatic lesion group consisted of 33 patients with mediastinal nodes, 32 patients with retroperitoneal lesions, 8 patients with thickened esophagogastric walls, 4 cases with abdominal masses, 2 cases with liver masses and 1 case with a left adrenal mass. Among the 69 pancreatic lesions that were detected with the normal, moderate and HNP suction techniques, the sensitivities of slow-pull (90%) and 5 ml suction (86.7%) were increased compared with that of 10 ml suction (64%), but the specificity of slow-pull (75%) was worse than those of 5 ml (100%) and 10 ml suction (88.2%). Consequently, the accuracy of 5 ml suction (88.9%) was superior to those of slow-pull (85.7%) and 10 ml suction (77.4%). Similarly, among the non-pancreatic lesion cases, the sensitivities of slow-pull, 5 ml suction and 10 ml suction were 85.7, 84.6 and 64.7%, respectively, and the specificities were 50, 80 and 92.9%, respectively. The accuracy of 5 ml suction (83.3%) was superior to those of slow-pull (81.25%) and 10 ml suction (71.9%). Overall, the total accuracy of 5 ml suction (86.1%) was greater than those of slow-pull (83.3%) and 10 ml suction (69.9%). Collectively, these results indicated that the lesions were diagnosed more accurately with the EUS-FNA with 5 ml suction technique regardless of the lesion location.

Adequacy scores and tissue quality of specimens

The adequacy scores for histological diagnosis of the obtained tissues are shown in Fig. 4A. The numbers of adequate and inadequate samples in the slow-pull, 5 ml suction and 10 ml suction groups are provided in Fig. 4B. Among the samples obtained from the slow-pull group, 70.6% (24/34) were determined to be adequate for histological diagnosis. By comparison, 86.5 (32/37) and 85.9% (67/78) of the samples obtained from the 5 ml suction and 10 ml suction groups were found to be adequate for histological diagnosis. Therefore, the samples that were obtained for histopathological diagnosis using the 5 ml suction and 10 ml suction techniques were superior to those obtained using normal negative pressure (NNP), although no significant difference was observed (P=0.1118; χ2 test). By contrast, the samples obtained using 10 ml suction contained more blood compared with those obtained using slow-pull or 5 ml suction techniques (P=0.0056; χ2 test; Table IV).

Table IV.

Degree of the amount of blood in the specimens.

Table IV.

Degree of the amount of blood in the specimens.

Amount of blood0 ml, n (%)5 ml, n (%)10 ml, n (%)P-value (χ2 test)
Minimal12 (35.3)13 (35.1)10 (12.8)0.0056a
Moderate15 (44.1)15 (40.5)31 (39.7)
Significant  7 (20.5)  9 (24.3)37 (47.4)

a P<0.01.

Complications

Among the 149 enrolled patients with solid lesions, no complications developed following the EUS-FNA procedures.

Discussion

In the present retrospective comparative analysis, the use of the slow-pull and 5 ml suction techniques during EUS-FNA for pancreatic or non-pancreatic solid lesions with regular FNA needles (22-G) was associated with superior specificities and accuracies compared with the use of the 10 ml suction technique. Although the sensitivities of the cytological examinations conducted with 5 ml suction and 10 ml suction were worse than that of slow-pull, the increase in diagnostic yield based on histological examination resulted in improved overall diagnostic yields for the 5 ml suction and 10 ml suction techniques. Furthermore, the samples obtained using slow-pull and 5 ml suction contained less contamination with blood compared with those obtained with 10 ml suction. Collectively, these results indicated that the lesions were diagnosed more accurately using EUS-FNA with 5 ml suction techniques regardless of the lesion location.

The requirement for suction during EUS-FNA has been evaluated in previous reports but remains controversial (24,29,30). The application of suction in EUS-FNA was first investigated during the sampling of lymph nodes. In a previous study on the application of EUS-FNA to malignant lymph nodes that were dissected at autopsy (31), continuous and intermittent suction with syringes of between 10 and 30 ml were compared, and continuous low-level suction resulted in optimum cellularity. Another study by Wallace et al (32) compared the application of EUS-FNA with and without suction to lymph nodes, and the application of suction increased the cellularity but decreased the specimen quality due to blood contamination. In another previous randomized controlled trial on the application of EUS-FNA with and without suction to pancreatic solid masses (33), which utilized 22 and 25-G needles, the application of suction resulted in greater cellularity, bloodiness and sensitivity. Therefore, the effect of suction during EUS-FNA for pancreatic masses has not yet been fully elucidated. However, the use of suction during EUS-FNA is generally considered to increase the cellularity and blood contamination, which may hinder cytological interpretation.

The European Society of Gastrointestinal Endoscopy (Munich, Germany) technical guidelines advocate the use of suction for the EUS-FNA of solid masses/cystic lesions (34). However, regarding the application of EUS-FNA to lymph nodes (22), the types of negative pressure that should be used with pancreatic and non-pancreatic solid lesions remain vague. Therefore, three different types of negative pressure suction techniques were utilized: A normal condition without negative pressure or a stylet; a moderate negative pressure condition using a 5 ml syringe; and a HNP condition using a 10 ml syringe. The results of the present study revealed that EUS-FNA with the 5 ml suction technique enabled superior specificity and accuracy compared with the 10 ml suction technique, and greater sensitivity of cytological examination compared with the slow-pull technique.

A total of two previous studies have indicated that EUS-FNA approaches that employ HNP suction for the aspiration of tissue enable the acquisition of adequate tissue samples (24,28). In addition, a technique has been proposed that reportedly enables the acquisition of tissue cores for histological assessment with standard 22 or 25-G EUS-FNA needles (29,30). The needle is connected to a balloon inflation gun (Alliance II inflation system; Microvasive Endoscopy, Boston Scientific Corporation, Marlborough, MA, USA), which is turned into suction mode to apply HNP (35–60 ml). In a previous study, Larghi et al (24) applied this technique prospectively in 27 patients with solid masses. These authors reported that tissue samples for histological examination were obtained in 96% of the cases. Kudo et al (23) also used this system and confirmed that biopsy procedures involving the combination of EUS-FNA and HNP techniques of between 35 and 60 ml, are superior to EUS-FNA combined with 10 ml negative pressure procedures in terms of tissue acquisition. One identified problem with the use of EUS-FNA with HNP is that the obtained specimens contain more blood. However, there were no differences between HNP and NNP in terms of diagnostic accuracy. Consequently, as demonstrated in the present study, the samples obtained using 5 ml suction contained less blood contamination compared with those obtained using 10 ml suction. In addition, the samples obtained for histopathological diagnosis via 5 ml suction remained superior to those obtained using slow-pull, although this difference was not significant. Therefore, it appears that the application of EUS-FNA with 5 ml suction is preferable for the diagnosis of mediastinal and intra-abdominal lesions compared with techniques that employ negative pressure applied with slow-pull and 10 ml suction techniques.

There were a number of limitations in the protocol of the present study. One limitation was the relatively low number of cases. The low number of randomized lesions also led to uneven randomization of the different target lesions and diagnostic entities, which may have affected the results. The majority of the patients presented with malignancies and only a few had benign tumors. Specifically, only a few patients possessed hypervascular tumors (n=9, neuroendocrine tumors). Additionally, this is an observational and retrospective study. Although the majority of baseline characteristics are balanced, selective bias and heterogeneity could not be avoided. Although the evidence presented here indicated that EUS-FNA with 5 ml suction is feasible, an additional multicenter, prospective, double-blind, randomized, controlled crossover trial study will be performed to resolve these issues.

Acknowledgements

The present study was supported by the National Science Foundation of China (grant nos. 81172063 and 81372352), and the Innovation Foundation of Huazhong University of Science and Technology. Dr Ronghua Wang was supported by the China Scholarship Association. The authors thank Dr Patrick Varley and Dr Hai Huang (both from Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA), and Dr Wensheng Zhang (Department of Med-Plastic Surgery, University of Pittsburgh, Pittsburgh, PA, USA) for their review of the present manuscript.

References

1 

Abdalla EK and Pisters PW: Staging and preoperative evaluation of upper gastrointestinal malignancies. Semin Oncol. 31:513–529. 2004. View Article : Google Scholar : PubMed/NCBI

2 

Pei Q, Wang L, Pan J, Ling T, Lv Y and Zou X: Endoscopic ultrasonography for staging depth of invasion in early gastric cancer: A meta-analysis. J Gastroenterol Hepatol. 30:1566–1573. 2015. View Article : Google Scholar : PubMed/NCBI

3 

Guo T, Yao F, Yang AM, Li XY, Zhong DR, Wu DS, Wu X and Lu XH: Endoscopic ultrasound in restaging and predicting pathological response for advanced gastric cancer patients after neoadjuvant chemotherapy. Asia Pac J Clin Oncol. 10:e28–e32. 2014. View Article : Google Scholar : PubMed/NCBI

4 

Chandran S, Efthymiou M, Kaffes A, Chen JW, Kwan V, Murray M, Williams D, Nguyen NQ, Tam W, Welch C, et al: Management of pancreatic collections with a novel endoscopically placed fully covered self-expandable metal stent: A national experience (with videos). Gastrointest Endosc. 81:127–135. 2015. View Article : Google Scholar : PubMed/NCBI

5 

Iglesias-Garcia J, Lariño-Noia J, Vallejo-Senra N, de-la-Iglesia-Garcia D, Abdulkader-Nallib I and Dominguez-Muñoz JE: Feasibility of endoscopic ultrasound (EUS) guided fine needle aspiration (FNA) and biopsy (FNB) with a new slim linear echoendoscope. Rev Esp Enferm Dig. 107:359–365. 2015.PubMed/NCBI

6 

Singh R, Jayanna M, Wong J, Lim LG, Zhang J, Lv J, Liu D, Lee YC, Han ML, Tseng PH, et al: Narrow-band imaging and white-light endoscopy with optical magnification in the diagnosis of dysplasia in Barrett's esophagus: Results of the Asia-Pacific barrett's consortium. Endosc Int Open. 3:E14–E18. 2015.PubMed/NCBI

7 

Barawi M and Gress F: EUS-guided fine-needle aspiration in the mediastinum. Gastrointest Endosc. 52:(6 Suppl). S12–S17. 2000. View Article : Google Scholar : PubMed/NCBI

8 

Horwhat JD and Gress FG: Defining the diagnostic algorithm in pancreatic cancer. JOP. 5:289–303. 2004.PubMed/NCBI

9 

Fritscher-Ravens A: Endoscopic ultrasound evaluation in the diagnosis and staging of lung cancer. Lung Cancer. 41:259–267. 2003. View Article : Google Scholar : PubMed/NCBI

10 

Shami VM, Parmar KS and Waxman I: Clinical impact of endoscopic ultrasound and endoscopic ultrasound-guided fine-needle aspiration in the management of rectal carcinoma. Dis Colon Rectum. 47:59–65. 2004. View Article : Google Scholar : PubMed/NCBI

11 

Lee YT, Chan FK, Leung WK, Chan HL, Wu JC, Yung MY, Ng EK, Lau JY and Sung JJ: Comparison of EUS and ERCP in the investigation with suspected biliary obstruction caused by choledocholithiasis: A randomized study. Gastrointest Endosc. 67:660–668. 2008. View Article : Google Scholar : PubMed/NCBI

12 

Ribeiro A, Vazquez-Sequeiros E, Wiersema LM, Wang KK, Clain JE and Wiersema MJ: EUS-guided fine-needle aspiration combined with flow cytometry and immunocytochemistry in the diagnosis of lymphoma. Gastrointest Endosc. 53:485–491. 2001. View Article : Google Scholar : PubMed/NCBI

13 

Erickson RA, Sayage-Rabie L and Beissner RS: Factors predicting the number of EUS-guided fine-needle passes for diagnosis of pancreatic malignancies. Gastrointest Endosc. 51:184–190. 2000. View Article : Google Scholar : PubMed/NCBI

14 

Mesa H, Stelow EB, Stanley MW, Mallery S, Lai R and Bardales RH: Diagnosis of nonprimary pancreatic neoplasms by endoscopic ultrasound-guided fine-needle aspiration. Diagn Cytopathol. 31:313–318. 2004. View Article : Google Scholar : PubMed/NCBI

15 

Klapman JB, Logrono R, Dye CE and Waxman I: Clinical impact of on-site cytopathology interpretation on endoscopic ultrasound-guided fine needle aspiration. Am J Gastroenterol. 98:1289–1294. 2003. View Article : Google Scholar : PubMed/NCBI

16 

Logroño R and Waxman I: Interactive role of the cytopathologist in EUS-guided fine needle aspiration: An efficient approach. Gastrointest Endosc. 54:485–490. 2001. View Article : Google Scholar : PubMed/NCBI

17 

Jhala NC, Jhala DN, Chhieng DC, Eloubeidi MA and Eltoum IA: Endoscopic ultrasound-guided fine-needle aspiration. A cytopathologist's perspective. Am J Clin Pathol. 120:351–367. 2003. View Article : Google Scholar : PubMed/NCBI

18 

Wani S, Gupta N, Gaddam S, Singh V, Ulusarac O, Romanas M, Bansal A, Sharma P, Olyaee MS and Rastogi A: A comparative study of endoscopic ultrasound guided fine needle aspiration with and without a stylet. Dig Dis Sci. 56:2409–2414. 2011. View Article : Google Scholar : PubMed/NCBI

19 

Rastogi A, Wani S, Gupta N, Singh V, Gaddam S, Reddymasu S, Ulusarac O, Fan F, Romanas M, Dennis KL, et al: A prospective, single-blind, randomized, controlled trial of EUS-guided FNA with and without a stylet. Gastrointest Endosc. 74:58–64. 2011. View Article : Google Scholar : PubMed/NCBI

20 

Mertz H and Gautam S: The learning curve for EUS-guided FNA of pancreatic cancer. Gastrointest Endosc. 59:33–37. 2004. View Article : Google Scholar : PubMed/NCBI

21 

Siddiqui UD, Rossi F, Rosenthal LS, Padda MS, Murali-Dharan V and Aslanian HR: EUS-guided FNA of solid pancreatic masses: A prospective, randomized trial comparing 22-gauge and 25-gauge needles. Gastrointest Endosc. 70:1093–1097. 2009. View Article : Google Scholar : PubMed/NCBI

22 

Puri R, Vilmann P, Săftoiu A, Skov BG, Linnemann D, Hassan H, Garcia ES and Gorunescu F: Randomized controlled trial of endoscopic ultrasound-guided fine-needle sampling with or without suction for better cytological diagnosis. Scand J Gastroenterol. 44:499–504. 2009. View Article : Google Scholar : PubMed/NCBI

23 

Kudo T, Kawakami H, Hayashi T, Yasuda I, Mukai T, Inoue H, Katanuma A, Kawakubo K, Ishiwatari H, Doi S, et al: High and low negative pressure suction techniques in EUS-guided fine-needle tissue acquisition by using 25-gauge needles: A multicenter, prospective, randomized, controlled trial. Gastrointest Endosc. 80:1030–1037.e1. 2014. View Article : Google Scholar : PubMed/NCBI

24 

Larghi A, Noffsinger A, Dye CE, Hart J and Waxman I: EUS-guided fine needle tissue acquisition by using high negative pressure suction for the evaluation of solid masses: A pilot study. Gastrointest Endosc. 62:768–774. 2005. View Article : Google Scholar : PubMed/NCBI

25 

Harris K, Maroun R, Attwood K and Chalhoub M: Comparison of cytologic accuracy of endobronchial ultrasound transbronchial needle aspiration using needle suction versus no suction. Endosc Ultrasound. 4:115–119. 2015. View Article : Google Scholar : PubMed/NCBI

26 

Alizadeh Mohammad AH, Hadizadeh M, Padashi M, Shahbaazi S, Molaee M and Shariatpanahi ZV: Comparison of two techniques for endoscopic ultrasonography fine-needle aspiration in solid pancreatic mass. Endosc Ultrasound. 3:174–178. 2014. View Article : Google Scholar : PubMed/NCBI

27 

Aadam AA, Oh YS, Shidham VB, Khan A, Hunt B, Rao N, Zhang Y, Tarima S and Dua KS: Eliminating the residual negative pressure in the endoscopic ultrasound aspirating needle enhances cytology yield of pancreas masses. Dig Dis Sci. 61:890–899. 2016. View Article : Google Scholar : PubMed/NCBI

28 

Gerke H, Rizk MK, Vanderheyden AD and Jensen CS: Randomized study comparing endoscopic ultrasound-guided Trucut biopsy and fine needle aspiration with high suction. Cytopathology. 21:44–51. 2010. View Article : Google Scholar : PubMed/NCBI

29 

Wang KX, Ben QW, Jin ZD, Du YQ, Zou DW, Liao Z and Li ZS: Assessment of morbidity and mortality associated with EUS-guided FNA: A systematic review. Gastrointest Endosc. 73:283–290. 2011. View Article : Google Scholar : PubMed/NCBI

30 

Haba S, Yamao K, Bhatia V, Mizuno N, Hara K, Hijioka S, Imaoka H, Niwa Y, Tajika M, Kondo S, et al: Diagnostic ability and factors affecting accuracy of endoscopic ultrasound-guided fine needle aspiration for pancreatic solid lesions: Japanese large single center experience. J Gastroenterol. 48:973–981. 2013. View Article : Google Scholar : PubMed/NCBI

31 

Bhutani MS, Suryaprasad S, Moezzi J and Seabrook D: Improved technique for performing endoscopic ultrasound guided fine needle aspiration of lymph nodes. Endoscopy. 31:550–553. 1999. View Article : Google Scholar : PubMed/NCBI

32 

Wallace MB, Kennedy T, Durkalski V, Eloubeidi MA, Etamad R, Matsuda K, Lewin D, Van Velse A, Hennesey W, Hawes RH and Hoffman BJ: Randomized controlled trial of EUS-guided fine needle aspiration techniques for the detection of malignant lymphadenopathy. Gastrointest Endosc. 54:441–447. 2001. View Article : Google Scholar : PubMed/NCBI

33 

Lee JK, Choi JH, Lee KH, Kim KM, Shin JU, Lee JK, Lee KT and Jang KT: A prospective, comparative trial to optimize sampling techniques in EUS-guided FNA of solid pancreatic masses. Gastrointest Endosc. 77:745–751. 2013. View Article : Google Scholar : PubMed/NCBI

34 

Polkowski M, Larghi A, Weynand B, Boustière C, Giovannini M, Pujol B and Dumonceau JM: European Society of Gastrointestinal Endoscopy (ESGE): Learning, techniques, and complications of endoscopic ultrasound (EUS)-guided sampling in gastroenterology: European Society of Gastrointestinal Endoscopy (ESGE) technical guideline. Endoscopy. 44:190–206. 2012. View Article : Google Scholar : PubMed/NCBI

Related Articles

Journal Cover

May 2017
Volume 13 Issue 5

Print ISSN: 1792-1074
Online ISSN:1792-1082

Sign up for eToc alerts

Recommend to Library

Copy and paste a formatted citation
APA
Wang, R., Wang, J., Li, Y., Duan, Y., Wu, X., & Cheng, B. (2017). Diagnostic accuracies of endoscopic ultrasound-guided fine-needle aspiration with distinct negative pressure suction techniques in solid lesions: A retrospective study. Oncology Letters, 13, 3709-3716. https://doi.org/10.3892/ol.2017.5942
MLA
Wang, R., Wang, J., Li, Y., Duan, Y., Wu, X., Cheng, B."Diagnostic accuracies of endoscopic ultrasound-guided fine-needle aspiration with distinct negative pressure suction techniques in solid lesions: A retrospective study". Oncology Letters 13.5 (2017): 3709-3716.
Chicago
Wang, R., Wang, J., Li, Y., Duan, Y., Wu, X., Cheng, B."Diagnostic accuracies of endoscopic ultrasound-guided fine-needle aspiration with distinct negative pressure suction techniques in solid lesions: A retrospective study". Oncology Letters 13, no. 5 (2017): 3709-3716. https://doi.org/10.3892/ol.2017.5942